Maternal ATI Practice B

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the med. For which of the following findings should the nurse instruct the client to notify the provider? A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness

A. Shortness of breath

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? A. Place a rolled towel beneath one of the client's hips B. Apply internal upward pressure to the presenting part using two gloved fingers C. Administer oxygen to the client via a nonrebreather mask at 10L/min D. Increase the IV infusion rate

B. Apply internal upward pressure to the presenting part using two gloved fingers

The nurse is preparing the client for surgery. Which of the following actions should the nurse take?

Ensure the client is NPO prior to surgery Insert an 18g peripheral IV prior to surgery Obtain a complete blood count Verify a consent form is signed by the client

Leopold maneuver sequence

Palpate client's fundus to identify fetal part, determine location of fetal back, palpate fetal part presenting at inlet, identify attitude of head

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. What client history would be CI? SATA A. Cholecystitis B. Hypertension C. Human papillomavirus D. Migraine headaches E. Anxiety disorder

A. Cholecystitis B. Hypertension D. Migraine headaches

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? A. Calcium B. Vitamin E C. Iron D. Vitamin D

C. Iron

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? A. "You should take the med w/in 72 hr following unprotected sexual intercourse" B. "You should avoid taking this medication if you are on oral contraceptives" C. If you don't start your period within 5 days of taking this med, you will need a pregnancy test"

A. " You should take this medication within 72 hrs following unprotected sexual intercourse

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious. Which response should the nurse make? A. "You can miss your period for several other reasons" B. "If you have been sexually active and haven't used protection, it is likely you are pregnant" C. "Let's check to see if you have any other signs of pregnancy" D. "Because you have missed your period, you should take a home pregnancy test"

A. "You can miss your period for several other reasons. Describe your typical menstrual cycle"

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? A. "You can share your room with your baby for the next few weeks" B. "Cover your baby with a light blanket while sleeping" C. "Check the temperature of your baby's bath water with your hand" D. "Your baby can nap in the car seat during the daytime"

A. "You can share your room with your baby for the next few weeks"

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? A. Apply sacral counterpressure B. Perform TENS C. Initiate slow-pace breathing D. Assist with biofeedback

A. Apply sacral counterpressure

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? A. Bilirubin 9 mg/dL B. Hemoglobin 18 g/dL C. Platelets 175,000/mm3 D. Hematocrit 45%

A. Bilirubin 9 mg/dL Above expected reference range ( 2-6 mg/dL)

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? A. Cover the newborn's eyes while under the phototherapy light B. Keep the newborn in a shirt while under the phototherapy light C. Apply a light moisturizing lotion to the newborn's skin D. Turn and reposition the newborn every 4 hours while undergoing phototherapy

A. Cover the newborn's eyes while under the phototherapy light

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura. Which of the following findings should the nurse expect? A. Decreased platelet count B. Increased erythrocyte sedimentation rate C. Decreased megakaryocytes D. Increased WBC

A. Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? A. Determine respiratory function B. Increase the IV fluid rate C. Access emergency medication from cart D. Collect a maternal blood sample for coagulopathy studies

A. Determine respiratory function

A nurse in the antepartum clinic is assessing a client's adaption to pregnancy. The client states that she is, "happy one min and crying the next". The nurse should interpret the statement as indication of? A. Emotional lability B. Focusing phase C. Cognitive restructuring D. Couvade syndrome

A. Emotional lability

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for admin of this med? SATA A. Flaccid uterus B. Cervical laceration C. Excess vaginal bleeding D. Increased afterbirth cramping E. Increased maternal temperature

A. Flaccid uterus B. Excess vaginal bleeding

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A. Jitteriness B. Hypertonia C. Abdominal distention D. Mottling

A. Jitteriness

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take? A. Massage the client's fundus B. Insert an indwelling urinary catheter C. Administer oxygen at 10L/min D. Elevate the client's right hip

A. Massage the client's fundus

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? A. Oligohydramnios B. Hyperemesis gravidarum C. Leukorrhea D. Periodic tingling of the fingers

A. Oligohydramnios

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? A. Swelling of the face B. Varicose veins in the calves C. Nonpitting 1+ ankle edema D. Hyperpigmentation of the cheeks

A. Swelling of the face Swelling of the face/sacral area/fingers can indicated HTN or pre-E

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Indication for medical administration? A. "This medication will stop your labor" B. "This medication stimulates fetal lung maturity" C. "This med will decrease your risk for uterine infections" D. "This med will increase your baby's weight"

B. "This medication stimulates fetal lung maturity"

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? A. "You should replace the diaphragm every 5 years" B. "You should leave the diaphragm in place for at least 6 hrs after intercourse" C. "You should use an oil-based product as a lubricant when inserting the diaphragm" D. "You should insert the diaphragm when your bladder is full"

B. "You should leave the diaphragm in place for at least 6 hrs after intercourse"

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contraction 2-3 min apart, each lasting 80-90 sec, and a vaginal exam reveals cervix 9 cm dilated. Phase of labor? A. Passive descent B. Active C. Early D. Descent

B. Active

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharm intervention should the nurse include in the plan of care for lactation suppression A. Place warm, moist packs on the breast B. Apply cabbage leaves on the breast C. Wear a loose-fitting bra D. Put green tea bags on the breasts

B. Apply cabbage leaves on the breast

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? A. Decreased heart rate B. Chin quivering C. Pinpoint pupils D. Slowed respirations

B. Chin quivering

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? A. Tell the client to follow up with a dermatologist B. Explain to the client this is an expected occurrence C. Instruct the client to increase her intake of vitamin D D. Inform the client she might have an allergy to her skin care products

B. Explain to the client this is an expected occurrence

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler in which of the following locations to begin assessing FHT A. Just above the umbilicus B. Just above the symphysis pubis C. The right lower quadrant D. The left lower quadrant

B. Just above the symphysis pubis

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? A. Increased fetal movement B. Leakage of fluid from the vagina C. Upper abdominal discomfort D. Urinary frequency

B. Leakage of fluid from the vagina Could indicate premature leakage of amniotic fluid and should be reported

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. What instruction should the nurse include? A. Place the shoulder harness in the slots above the newborn's shoulders B. Place the retainer clip at the level of the newborn's armpits C. Place the newborn at a 60 degree angle in the car seat D. Place the newborn in a blanket before securing them in the car seat

B. Place the retainer clip at the level of the newborn's armpits

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? A. O2 saturation B. Temperature C. Blood pressure D. Urinary output

B. Temperature Can indicate an infection

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? A. Confirm the newborn's Apgar score. B. Verify the newborn's identification C. Administer vitamin K to the newborn D. Determine obstetrical risk factor

B. Verify the newborn's identification

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? A. "You will need to drink the glucose solution 2 hrs prior to the test" B. "Limit your carbohydrate intake 3 days prior to the test" C. "A blood glucose of 130-140 is considered a positive screening result" D. "You will need to fast for 12 hr prior to the test"

C. "A blood glucose of 130-140 is considered a positive screening result"

A nurse is teaching a client who has pre-gestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should have a goal of maintaining my fasting blood glucose between 100-120" B. "I should engage in moderate exercise for 30 min if my blood glucose is 250 or greater" C. "I will continue taking my insulin if I experience nausea and vomiting"

C. "I will continue taking my insulin if I experience nausea and vomiting"

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? A." I will get injections of the medication once daily until my labor stops" B. "My blood sugar may be low while on this med" C. "I will have blood test because my potassium might decrease" D. "My blood pressure may increase while on this med"

C. "I will have blood tests because my potassium might decrease"

A nurse is assessing a client who gave birth vaginally 12 hrs ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? A. Reassess the client in 2 hrs B. Administer simethicone C. Assist the client to empty her bladder D. Instruct the client to lie on her right side

C. Assist the client to empty her bladder

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? A. Percutaneous umbilical blood sampling B. Amnioinfusion C. Biophysical profile D. Chorionic villus sampling

C. Biophysical profile

A nurse is reviewing the laboratory report of a newborn who is 24 hrs old. Which of the following results should the nurse report to the provider? A. Hgb 20 g/dL B. Total bilirubin 5 mg/dL C. Blood glucose 30 mg/dL D. WBC count 20,000/mm3

C. Blood glucose 30 mg/dL Below expected reference range. Should be 40-45 mg/dL

A nurse is assessing FHT. Fetal position as left occipital anterior. Which of the following areas of the client's abdomen should the nurse apply the Doppler? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

C. Left lower quadrant

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Plan of care? A. Place the client in a supine position for 30 min following the first dose of anesthetic solution B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution C. Monitor the client's blood pressure Q 5 min following the first dose D. Ensure the client is NPO 4 hrs prior

C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations require intervention by the nurse? A. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex

C. Substernal chest retractions while sleeping Indicate respiratory distress syndrome in the newborn

A nurse is teaching a postpartum client about steps the nurse will take to promote the security and safety of the client's newborn. Which statement should the nurse make? A. "The nurse will carry your newborn to the nursery for procedures" B. "We will document the relationship of visitors in your medical record C. "Your baby will stay in the nursery while you are asleep" D. "Staff members who take care of your baby will be wearing a photo identification badge"

D "Staff members who take care of your baby will be wearing a photo identification badge"

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? A. "I will receive this med if my baby is Rh-negative" B. "I will receive this med when I am in labor" C. "I will need a second dose of this med when my baby is 6 weeks old" D. "I will need this med if I have an amniocentesis"

D. "I will need this medication if I have an amniocentesis" Due to the potential of fetal RBC's entering the maternal circulation

A nurse is planning care for a client who is 2 hours postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? A. Discuss contraceptive options with the client and her partner B. Repeat information to ensure client understanding C. Listen to the client and her partner as they reflect upon the birth experience D. Demonstrate to the client how to perform a newborn bath

D. Demonstrate to the client how to perform a newborn bath

A nurse is planning care for a client who is to undergo a nonstress test. What action should the nurse include in the plan of care? A. Maintain the client NPO throughout procedure B. Place the client in a supine position C. Instruct the client to massage the abdomen to stimulate fetal movement D. Instruct the client to press the provided button each time fetal movement is detected

D. Instruct the client to press the provided button each time fetal movement is detected

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? A. Hct 39% B. Serum album 4.5 g/dL C. WBC 9,000/mm3 D. Platelets 50,000/mm3

D. Platelets 50,000/mm3 Below expected reference range. Can indicate DIC

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? A. Insert the syringe tip before compressing the bulb B. Suction each of the nares before suctioning the mouth C. Insert the tip of the syringe into the center of the newborn's mouth D. Stop suctioning when the newborn's cry sounds clear

D. Stop suctioning when the newborn's cry sounds clear

A nurse is assessing the newborn of a client who took a SSRI during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? A. Large for gestational age B. Hyperglycemia C. Bradypnea D. Vomiting

D. Vomiting Expected manifestations include irritability, agitation, tremors, diarrhea and vomiting